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2 ACKNOWLEDGEMENTS This white paper was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA) by the Suicide Prevention Action Network USA, under contract number [ TK002] with the Center for Substance Abuse Treatment, SAMHSA, U.S. Department of Health and Human Services (HHS). It was reviewed and revised by Theodora Fine, M.A., under a purchase order implemented by the SAMHSA Office of Communications and Jorielle Brown, Ph.D., the Government Project Officer. DISCLAIMER The views, opinions, and content of this publication are those of the authors and do not necessarily reflect the views, opinions, or policies of SAMHSA or HHS. PUBLIC DOMAIN NOTICE All material appearing in this report is in the public domain and may be reproduced or copied without permission from SAMHSA. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, and HHS. ELECTRONIC ACCESS AND COPIES OF PUBLICATION This publication may be downloaded at Or, please call SAMHSA s Health Information Network at SAMHSA-7 ( ) (English or Español). RECOMMENDED CITATION Center for Substance Abuse Treatment. Substance Abuse and Suicide Prevention: Evidence and Implications A White Paper. DHHS Pub. No. SMA Rockville, MD: Substance Abuse and Mental Health Services Administration, ORIGINATING OFFICE Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD DHHS Publication No. SMA , 2008.

4 INTRODUCTION Almost a decade ago, then-surgeon General David Satcher, MD, issued a Call to Action to Prevent Suicide (1999) as the first step toward adoption of a National Strategy on Suicide Prevention and the acknowledgement of suicide as an issue of public health concern and for national action. Recognizing that each year, over 30,000 individuals of all ages, races and ethnicities lose their lives by suicide in the U.S., Dr. Satcher observed that the difference between knowing and doing can be fatal. Pointing out that...even the most well considered plan accomplishes nothing if it is not implemented, he urged action to advance the Report s 15 key recommendations focused on awareness, intervention and methodology. The Call to Action called for the implementation of strategies to reduce the stigma associated not only with suicidal behavior and mental illnesses, but also with substance abuse disorders. It urged that resources be enhanced for suicide prevention programs and for mental and substance abuse disorder assessment and treatment. Moreover, it recommended that health care provider capacity be enhanced to better recognize and either refer or treat depression, substance abuse and other major mental illnesses associated with suicide risk. Since publication of the Call to Action, considerable necessary progress has been made, thanks to a confluence of concerted action by policymakers, administrators, researchers, clinicians, and families touched by suicide. The body of scientific knowledge about suicide prevention and intervention has grown markedly. Increasing numbers of evidence-based programs have been taking their place in the realm of best practices. The Garrett Lee Smith Memorial Act has resulted in the implementation of grant programs focused on youth suicide prevention in communities and on college campuses around the country. The Suicide Prevention Lifeline network of over 125 call centers is reaching out to reduce suicides one call at a time, including from populations at elevated risk, such as our nation s returning veterans. The Suicide Prevention Resource Center is facilitating dissemination of awareness messages and primary care education, giving the public and practitioners better suicide prevention tools than ever before. However, needed progress is not the same as sufficient progress. One of the critical issues that require further exploration and attention is the role of substance abuse in the interplay of factors that result in a greater risk for suicidal behaviors. This document focuses on the current state of knowledge at the intersection of suicide and substance abuse. The first section focuses on the epidemiology of suicide itself and presents a brief history of the growing focus on suicide as a public health issue of significant concern. The second section provides an overview of what we know and do not know of the impact of substance abuse including both drugs and alcohol on suicide risk. It also acknowledges the critical interrelationships among substance abuse, mental illness and suicide risk. The final section of the document explores suicide prevention within the public health context of behavioral health promotion and illness prevention. This document marks a first step toward greater knowledge. It soon will be supplemented by a far more extensive consensus-built Treatment Improvement Protocol on substance abuse and suicide. Despite the progress, much more remains to be done if we are to respond to the public health imperative posed by continuing high rates of suicide in the nation. It is time to end continued stovepipe approaches to prevention and treatment; it is time to change the focus from an acute care model of health care. Moreover, it is time to implement a more integrated, public health-oriented approach to suicide prevention one that takes into account the role of substance abuse disorders as well as mental illnesses and genetic, social and environmental factors, that takes in the continuum of care from prevention through long-term intervention. 1

5 SUICIDE: A NATIONAL, PREVENTABLE PUBLIC HEALTH PROBLEM The mind is its own place, and in itself can make a heaven of hell, a hell of heaven. John Milton Suicide is not a new phenomenon; it is centuries old. In some cultures, death by suicide was considered honorable; in others, it was considered immoral, a crime. Whether revered or reviled, suicide robs families, communities and societies around the world of thousands of its members each year. In a single year, in the United States alone, suicide was responsible for the deaths of over 32,000 people of all ages (Centers for Disease Control and Prevention 2007) and cost an estimated $11.8 billion in lost income (Goldsmith et al. 2002). Efforts to understand suicide, also, are not new. The 19th century sociologist, Emile Durkheim (1897/1951), wrote about the social context that may lead to suicide. However, like mental illnesses, substance abuse and other poorly understood illnesses such as cancer, suicide was a taboo topic for most people. Public health attention was on the prevention and treatment of better-understood, more visible acute illnesses across the population. For all of the damage to individuals and families, communities and economies, only in the past decade have suicide and the mental and substance use disorders to which the vast majority of suicide can be attributed become visible on the public health radar screen (U.S. Public Health Service 1999a, 1999b, 2001; New Freedom Commission on Mental Health 2003). Over the past decade, the situation has been changing for the better, in part, due to the growing public health approach to suicide prevention (U.S. Public Health Service 1999a; New Freedom Commission on Mental Health 2003; Mann et al. 2005). By moving the dial from an individual-by-individual approach to a population-based systems approach, suicide, increasingly, has been recognized as the product of the complex interaction of multiple factors some biological and some environmental spanning the sociocultural, interpersonal, psychological, genetic, and neurological spectra (U.S. Public Health Service 2001; Goldsmith et al. 2002). As a result of this growing understanding, knowledge and education are being spread across the public and among health professionals. Science is amassing an expanded knowledge base of complex factors that may lead to suicide and a greater understanding of the best ways to identify and intervene among those at risk. The critical role of mental illnesses in the mix of factors precipitating suicide attempts and completions has been well established in the literature (Moscicki 2001; U.S. Public Helath Service 2001; Goldsmith et al. 2002; Goldston, 2004). More recently, the impact of both alcohol and drug abuse on suicide risk particularly when accompanied by mental illness has been gaining greater traction in the literature as well. (See references). As the next section suggests, however, the pace, has been far too slow for far too many people of all ages, races and ethnicities. Due to the social stigma or lack of understanding, many individuals and health care providers do not recognize the signs or treat mental disorders with the same urgency as other medical conditions. As noted in the National Strategy on Suicide Prevention (2001), suicide remains a preventable tragedy for too many in America and around the world. The magnitude of suicide s impact makes it an issue for those engaged in improving the health of the nation and the world. Its relationship to behavioral disorders makes the issue of suicide and its prevention critical to the work of those in mental heath care, and substance abuse treatment and prevention. 2

6 10BUEpidemiology In the United States, almost 90 lives are lost to suicide each day, the equivalent of a death by suicide every 16 minutes (Centers for Disease Control and Prevention 2007). In 2005 (the most recent year for which data are available), suicide accounted for 32,637 deaths among people of all ages, and 31,610 among adults age 18 and up (Centers for Disease Control and Prevention 2006b). The 11th leading cause of death in the United States, suicide was responsible for more deaths in that year than homicide and HIV combined (Centers for Disease Control and Prevention 2006a). The human and economic costs of suicide ripple outward beyond the individual. In addition to those who die by suicide each year, as many as 200,000 additional individuals will be affected by the loss of a loved one or acquaintance to suicide (Corso et al. 2007). The total lifetime cost of self-inflicted injuries occurring in 2000 was approximately $33 billion. This includes $1 billion for medical treatment and $32 billion for lost productivity (Corso et al. 2007). Despite growing recognition of suicide as a problem demanding public health attention, overall rates of suicide in the U.S. have remained essentially stable for the last half-century (Goldsmith et al. 2002; National Center for Health Statistics 2008). FIGURE 1 Death Rates for Suicide by Sex, [Source: National Center for Health Statistics, 2007] 3

7 Population differences in suicide Suicide affects everyone, but some groups are at higher risk than others. Suicide rates vary by gender, ethnicity and age. Suicide is the eighth leading cause of death for men of all ages and the 16 th leading cause of death for women (Centers for Disease Control and Prevention 2005). Men are four times more likely than women to die from suicide, representing 78.8% of all U.S. suicides (Centers for Disease Control and Prevention 2006b). However, three times more women than men report attempting suicide (Krug et al. 2002). Firearms, suffocation and poison are by far the most common methods of suicide, overall. However, men and women differ in the method used (Centers for Disease Control and Prevention 2006b): TABLE 1 Suicide by Sex and Method Suicide by: Males (%) Females (%) Firearms Suffocation Poisoning [Source: Centers for Disease Control and Prevention 2006b] In addition, suicide rates are high among young people and those over age 65. Among those ages 25-34, suicide is the second leading cause of death, behind unintentional injuries. Suicides represent the third leading cause of death among year olds, nearly 13% of all deaths annually. Gender differences in suicide also arise among young people. Almost four times as many males as females ages 15 to 19 died by suicide (Centers for Disease Control and Prevention 2006a); more than six times as many males as females ages 20 to 24 died by suicide (Centers for Disease Control and Prevention 2006a). Moreover, for every suicide completed in the 15 to 24 age group in the U.S., there are attempted suicides (Arias et al. 2003). Suicide rates are highest in old age. Of every 100,000 people ages 65 and older, 14.3 die by suicide. This figure is markedly higher than the national average of 10.9 suicides per 100,000 people in the general population (Centers for Disease Control and Prevention 2006b). After age 75, the rate of suicide is three times higher than average (Mental Health America, 2008). Non-Hispanic white men age 85 or older had an even higher rate, with 17.8 suicide deaths per 100,000 (Centers for Disease Control and Prevention 2006b). Elderly people who die by suicide are often divorced or widowed and suffer from a physical illness. 4

8 [Source: National Center for Health Statistics] Race and ethnicity also can be factors that contribute to suicide risk. For example, suicide rates among American Indian/Alaska Native adolescents and young adults, ages 15-24, are almost two times higher than the national average for that age group (Centers for Disease Control and Prevention 2007). Young Indian women have rates of suicide that are two to three times higher than for females in the general population (Goldsmith et al. 2002). [Source: National Center for Health Statistics, 2007] 5

9 65 and up, estimates suggest there is one suicide for every four suicide attempts (Goldsmith et al. 2002). Among youth, in 2005, 16.9 percent of U.S. high school students reported they had seriously considered attempting suicide during the previous 12 months. More than eight percent reported they actually had attempted suicide at least once during the same period (Eaton et al. 2006). College students may be particularly vulnerable. The 2006 National College Health Assessment found that 44 percent of the students surveyed reported that they felt so depressed it was difficult to function during the past year; nearly one in 10 said that they had seriously considered suicide during the year (American College Health Association 2007). Those who attempt suicide and survive may have serious injuries like broken bones, brain damage or organ failure. Also, people who survive often experience depression and other mental health problems. The fact of a suicide attempt is a predictor of future, possibly fatal attempts (Moscicki 2001; Goldsmith et al. 2002; Eaton et al. 2006; Centers for Disease Control and Prevention 2007). Suicide and the risk for suicide also affect the health of the community. Family and friends of people who die by or attempt suicide may feel shame, shock, anger, guilt and depression. The taboo that surrounds suicide leads many people to silence at a time when reaching out for assistance is most critical. However, the stigma surrounding suicide like mental and substance abuse disorders before it is lifting. Suicide and the need for suicide prevention, once hardly a matter for public conversation, are becoming a matter of public health and public concern. A national poll conducted for the Suicide Prevention Action Network (SPAN) USA and Research!America (2006) found that over three-quarters of Americans (78%) believe many suicides could have been prevented; four out of five Americans (86%) support the value of a greater national investment in suicide prevention. These findings suggest the message that suicide is a preventable health problem is being heard and heeded, thanks in large part to the confluence of science and policy, program and the power of people. Moving Toward Recognition If the general public understands that suicide and suicidal behaviors can be prevented, and people are made aware of the roles individuals and groups can play in prevention, many lives can be saved National Strategy for Suicide Prevention Over the last decade, policymakers, clinicians, administrators, and public health experts have begun to take action against suicide both within the United States and around the world. In 1996, the World Health Organization (WHO), recognizing the growing problem of suicide worldwide, urged member nations to address suicide in its document Prevention of Suicide: Guidelines for the Formulation and Implementation of National Strategies. This Report motivated the Surgeon General to determine in 1999 that suicide is a public health problem and to issue a Call to Action to Prevent Suicide. It urged establishment of a national strategy to prevent suicide, relying on the expertise of the Substance Abuse and Mental Health Services Administration (SAMHSA), the Centers for Disease Control and Prevention (CDC), the Health Resources and Service Administration (HRSA), the Indian Health Service (IHS), the National Institute on Mental Health (NIMH), and the Office of the Surgeon General, as well as the Suicide Prevention Advocacy Network (SPAN USA) and other advocacy and stakeholder organizations. Just two years later, in 2001, the first installment of the National Strategy for Suicide Prevention (NSSP) was unveiled. The document established 11 goals and 68 measurable objectives for public and private sector involvement to prevent suicides and attempts, as well as to reduce the harmful after-effects they have on families and communities. Its goals and objectives laid out a framework for action and a guide for the development of an array of services and programs. During the same period, the quasi- 6

10 governmental Institute of Medicine convened two workshops on suicide prevention, leading to the 2002 publication of its landmark report, Reducing Suicide: A National Imperative. These reports, coupled with the final report of the President s New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in America (2003), have helped bring attention to the burden of suicide on our nation and the need for concerted prevention initiatives. The Commission s very first recommendation focuses on suicide prevention as a key element of a comprehensive mental health system, urging the President to advance and implement a national campaign to reduce the stigma of seeking care and a national strategy for suicide prevention. Critically, three of the 11 goals of the National Strategy for Suicide Prevention (2001) highlight the role that substance abuse increasingly plays as a risk factor for suicide, adding impetus to a growing body of knowledge and practice in this important area of suicide prevention. Specifically, Goal Three calls for the development and implementation of strategies to reduce the stigma associated with being a consumer of mental health, substance abuse and suicide prevention services. Goal Seven emphasizes the need for effective suicide prevention-related clinical and professional practices (from screening through treatment and referral, as warranted) by health care providers, including those involved in substance abuse treatment. Goal Eight promotes efforts to increase access to and community linkages with mental health and substance abuse services. Individually, these reports mark important steps toward greater recognition of suicide as a public health issue. Taken together, however, the reports provide a roadmap that, if followed, can help ensure that the suicide prevention and the behavioral health care communities are working together to save lives. That roadmap is being followed, thanks to the growing concern about suicide and suicide prevention that has galvanized the Congress, the Federal Executive Branch, and concerned communities, organizations and individuals around the country to action. During the 105 th Congress, the House and Senate enacted resolutions acknowledging suicide as a national problem that warrants a national response (S. Res. 84 and H.Res. 212). Since then, Congress has authorized the establishment of and directed funding to several suicide prevention programs, including the Garret Lee Smith Memorial Act (PL ) that established a series of programs designed to address youth suicide. Building from the NSSP, 46 states have developed a suicide prevention plan, many based on the model of the NSSP. The majority of these states have developed their plans through coalitions or task forces, most of which include representatives from government agencies, suicide survivors, advocates and other concerned individuals. As the lead agency charged with implementation of suicide prevention initiatives, SAMHSA has supported the establishment of a national toll-free hotline (the National Suicide Prevention Lifeline), a technical assistance center (the Suicide Prevention Resource Center), and a youth suicide prevention grant program for states and colleges (consistent with authority under the Garrett Lee Smith Memorial Act). Beginning in 2008, SAMHSA s National Survey on Drug Use and Health will ask all respondents about suicide attempts, whether or not they had previously acknowledged a major depression. This is an important step forward in suicide surveillance, promoting greater attention to the interrelationships among suicide and substance abuse. Moreover, the Agency also has been supporting the identification, development and dissemination of best practices in suicide prevention, focusing on risk and protective factors related to suicide with particular attention to mental health and substance abuse issues affecting suicide risk. To that end, SAMHSA s Center for Substance Abuse Treatment is developing a Treatment Improvement Protocol to focus on substance abuse and suicide prevention/risk assessment for substance abuse service providers. 7

11 The convergence of the data and increased recognition of suicide as a matter for health policy, programs, advocacy and education is what makes the issue one of urgent public health priority. The time simply is right for action. The role for behavioral health professionals cannot be overstated because the interconnections among mental illnesses, substance abuse and suicide, described in the next section of this white paper, are at the core of the public health approach to suicide prevention an approach highlighted in the final section of this paper. 8

12 SUICIDE AND SUBSTANCE USE DISORDERS A focus on the primary prevention of alcohol and drug use disorders and other psychopathological disorders associated with suicide, as well as intervention for those showing early indication of such disorders, are needed in order to have a meaningful impact on the population rate of suicide. -- Wilcox, Conner and Caine (2004, p. S18) Suicide has been spotlighted as a national public health issue (U.S. Public Health Service 1999; Goldsmith et al. 2002; New Freedom Commission on Mental Health 2003; U.S. Department of Health and Human Services 2007), and as such, its two most significant risk factors, mental and substance abuse disorders, must also be seen in that same light. While 95 percent of individuals with a mental illness and/or substance use disorder will never complete suicide, several decades of evidence consistently suggests that as many as 90 percent of individuals who do complete suicide experience a mental or substance use disorder, or both (Harris and Barraclough 1997; Pages et al. 1997; Moscicki 2001; Conwell et al 1996, Molnar et al (reported in IOM 2002)). The vast majority experience a mood disorder, such as depression (Moscicki 2001); as many as 25 percent experience alcohol abuse disorders (Institute of Medicine 2002). Many experience co-occurring mental and substance use disorders. Unfortunately, despite ongoing efforts to educate the public, the same social stigma that surrounds suicide also continues to stand between many people with mental and substance use disorders and the care they need care that could help thwart potential suicide. According to SAMHSA s 2006 National Survey on Drug Use and Health (NSDUH), of the 23.6 million people aged 12 or older in need of treatment for an illicit drug use or alcohol use problem only 2.5 million received treatment at a specialty facility (Office of Applied Studies 2007d). In the same year, among the 24.9 million adults aged 18 or older reporting serious psychological distress (having a level of symptoms known to be indicative of a mental disorder) fewer than half, 10.9 million (44.0 percent), received treatment for a mental health problem (Office of Applied Studies 2007d). The significant gap between needing and getting care for mental disorders and substance use problems and the role both play in suicide underscore the public health imperative of preventing behavioral health problems in the first place where possible, and otherwise identifying and treating them early in their course. Independent of each other, mental illnesses, substance abuse and suicide each have a profound impact on individuals and families, schools and workplaces, communities and society at large. The human and economic costs of these public health problems are significant. When each of these three problems is examined separately, it becomes clear that, in many instances and for many individuals, each one is related in some way to the other two. Thus, the co-occurrence of mental and substance abuse disorders today is the expectation rather than the exception (U.S. Public Health Service 1999; Goldsmith et al. 2002; Substance Abuse and Mental Health Services Administration 2002; New Freedom Commission on Mental Health 2003). The role mental illness plays in suicide risk, attempt and completion has been documented extensively in the scientific literature and will not be revisited in this white paper. Thus, the next section explores the growing body of evidence being amassed with respect to suicide and substance abuse and the interconnections among suicide and mental and substance abuse disorders. 9

13 Substance Use Disorders and Suicide: The Big Picture A growing body of studies has demonstrated that alcohol and drug abuse are second only to depression and other mood disorders as the most frequent risk factors for suicide (cited in IOM 2002). Molnar and colleagues assessment (2001) of data from the National Comorbidity Survey disclosed that alcohol and drug abuse disorders are associated with a risk 6.2 times greater than average risk of suicide attempts. According to SAMHSA s Drug Abuse Warning Network latest report on drug-related emergency department (ED) visits, in 2005, over 132,500 visits to emergency rooms were for alcohol- or drug-related suicide attempts. Substantial percentages of suicide victims tested positive for alcohol or other drugs. The most frequently identified substance was alcohol, found in one third of those tested; four other substances were identified in approximately 10 percent of tested victims. Illicit drugs were involved in approximately one fifth (19%) of the ED visits for drug-related suicide attempts. Over 85 percent of individuals associated with these attempts were seriously ill enough to merit admission to a hospital or another health care facility (Office of Applied Studies 2007c). The Drug Abuse Warning Network also has examined emergency department visits for drug-related suicide attempts by youth. In 2004, the most recent year for which data are available, reporting emergency departments handled over 15,000 drug-related suicide attempts by youth, ages 12-17, almost 75 percent of which were serious enough to warrant hospitalization. Around half of all of these suicide attempts involved the use of pain medications (Office of Applied Studies 2006a). These data do not suggest that all of the individuals who attempted suicide, whether young or adult, were experiencing substance abuse disorders; rather the data inform only that alcohol or drugs of abuse were used in what was characterized as a suicide attempt. Nonetheless, the sheer numbers are compelling. Field-based studies have been ongoing to understand the relationships between substances of abuse and suicide. Significant studies have been based on psychological autopsies; only in the last few years have increasing numbers of prospective studies been conducted. Research is complicated and sometimes confounded by the complex interrelationships among mental and substance use disorders, combined with other biological, behavioral, environmental and social factors influencing suicide risk. Alcohol In 1938, Karl Menninger observed that alcohol dependence is a type of chronic suicide (in Hufford 2001). His observation has been found to be accurate over the decades during which the relationship between suicide and alcohol consumption, alcohol use and alcohol dependence has been studied. As many as onefourth of individuals who die by suicide are intoxicated with alcohol (IOM 2002). Today, the literature bearing on the role alcohol plays in suicide risk is considerably more robust than that associated with drug abuse and suicide. As Wilcox notes in her 2004 review of the link between drug use and suicidal behaviors among adolescents, the association between suicidal behavior and alcohol abuse has been long documented, dating back to the 1980s. An extensive body of literature primarily retrospective studies has established that active alcohol use or abuse is a powerful risk factor for suicide (reported in Conner et al. 2000). One of the more significant reasons posited for this association is the disinhibition resulting from alcohol use that occurs shortly prior to a suicide attempt (Hufford 2001; Wilcox 2004). Hufford s literature review (2001) suggests alcohol intoxication appears to play a more significant role as a proximal, rather than distal, risk factor for suicide. 10

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